A/B Medicare Administrative Contractor (MAC) and Contractor Billing Requirements for the IPPE (Rev. 2159, 04-04-11)

by  Jared Staheli
July 6th, 2015

Effective for dates of service on and after January 1, 2005, through December 31, 2008, contractors shall recognize the HCPCS codes G0344, G0366, G0367, and G0368 shown above in §80.1 for an IPPE. The type of service (TOS) for each of these codes is as follows:

G0344: TOS = 1

G0366: TOS = 5

G0367: TOS = 5

G0368: TOS = 5

Contractors shall pay physicians or qualified nonphysician practitioners for only one IPPE performed not later than 6 months after the date the individual’s first coverage begins under Medicare Part B, but only if that coverage period begins on or after January 1, 2005.

Effective for dates of service on and after January 1, 2009, contractors shall recognize the HCPCS codes G0402, G0403, G0404, and G0405 shown above in §80.1 for an IPPE. The TOS for each of these codes is as follows:

G0402: TOS = 1

G0403: TOS = 5

G0404: TOS = 5

G0405: TOS = 5

Under the MIPPA of 2008, contractors shall pay physicians or qualified nonphysician practitioners for only one IPPE performed not later than 12 months after the date the individual’s first coverage begins under Medicare Part B only if that coverage period begins on or after January 1, 2009.

Contractors shall allow payment for a medically necessary Evaluation and Management (E/M) service at the same visit as the IPPE when it is clinically appropriate. Physicians and qualified nonphysician practitioners shall use CPT codes 99201-99215 to report an E/M with CPT modifier 25 to indicate that the E/M is a significant, separately identifiable service from the IPPE code reported (G0344 or G0402, whichever applies based on the date the IPPE is performed). Refer to chapter 12, § 30.6.1.1, of this manual for the physician/practitioner billing correct coding and payment policy regarding E/M services.

If the EKG performed as a component of the IPPE is not performed by the primary physician or qualified NPP during the IPPE visit, another physician or entity may perform and/or interpret the EKG. The referring physician or qualified NPP needs to make sure that the performing physician or entity bills the appropriate G code for the screening EKG, and not a CPT code in the 93000 series. Both the IPPE and the EKG should be billed in order for the beneficiary to receive the complete IPPE service. Effective for dates of service on and after January 1, 2009, the screening EKG is optional and is no longer a mandated service of an IPPE if performed as a result of a referral from an IPPE.

Should the same physician or NPP need to perform an additional medically necessary EKG in the 93000 series on the same day as the IPPE, report the appropriate EKG CPT code(s) with modifier 59, indicating that the EKG is a distinct procedural service.

Physicians or qualified nonphysician practitioners shall bill the contractor the appropriate HCPCS codes for IPPE on the Form CMS-1500 claim or an approved electronic format. The HCPCS codes for an IPPE and screening EKG are paid under the Medicare Physician Fee Schedule (MPFS). The appropriate deductible and coinsurance applies to codes G0344, G0366, G0367, G0368, G0403, G0404, and G0405. The deductible is waived for code G0402 but the coinsurance still applies.

References:

A/B Medicare Administrative Contractor (MAC) and Contractor Billing Requirements for the IPPE (Rev. 2159, 04-04-11). (2015, July 6). Find-A-Code Articles. Retrieved from https://www.findacode.com/articles/a-b-medicare-administrative-contractor-mac-and-contractor-billing-requirements-for-the-ippe-rev-2159-04-04-11-27010.html

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